We have to hammer on abusers in every way possible. They are the culprits and the problem. They are reckless criminals.
—EMAIL FROM DR. RICHARD SACKLER, FORMER CHAIRMAN AND PRESIDENT OF PURDUE PHARMA, CURRENT BILLIONAIRE, FEBRUARY 1, 20011
Pharmacy tech was riding me about oxycontin [sic] being a bad drug. Corrected her by saying, good drug, bad people abusing it.
—PURDUE PHARMA SALES REP CALL NOTE, FEBRUARY 20, 20082
She talked; he wrote.
Tracy had a pink scar running across her cheek. Her hair was bottle-blond. She spoke quickly, nodding and gesturing to bring a story to life.
Dr. Li wore his white medical coat. He sat across from her, at the laminated wood desk in the small exam room. He looked down, reading the label on the prescription bottle that Tracy had given him, and filled out prescription forms.
She told him about the car accident—her blackout at the wheel, waking up in the hospital, getting up to go to the bathroom and falling down, the broken leg, her tongue ripped in two, the stitches in her mouth. The pain in her back, in her leg, in her ankle.
She told Dr. Li her life story—she wasn’t sure why but she did, perhaps because there was a part of her that was still five years old, sitting at the table with her daddy, looking at her daddy and his gun, reliving that moment over and over again. Wishing she could stop time just before it happened—and stop him—so that the rest of her life could be easier. But that’s not how it works.
So she told Dr. Li about her daddy shooting himself right there in front of her, just the two of them sitting at the table together.
From there, she went on to the next thing, as she tended to do, spilling out her entire story to make sure he understood the hurt: the sexual abuse, the rape, the car accident. Maybe it all sounded like a lot to him, but there was so much more. As she spoke it all unfurled in her mind, the times she’d ended up in the hospital and so many medications, psychiatric medications as she called them, to distinguish them from the other medications she’d been taking for her asthma, her heart, her blood pressure, her depression, her physical pain, and then there were illegal drugs: the crack cocaine, the heroin, whatever she could get her hands on, that answered a deeper call for something that wasn’t relief; it was more than that, stronger than that—
“What do you need?” asked Dr. Li.
There were so many things she needed. What was he referring to? His pen hovered over the prescription form. He held the prescription bottle in his other hand. Oh—he just wanted to know what she wanted.
“Oxycodone,” she said.
“I can give you two prescriptions,” he said.
“How much would that be?”
“One hundred fifty dollars.”
Okay. She had it. She had $150. So she’d take two prescriptions, if that’s what he was offering.
He wrote the other prescription for Xanax, the sticks, as she called them. And that was it. Had he heard her? Had he seen her? She handed him the money. He put it right into the pocket of his white lab coat.
Numb. That’s what she’d always wanted to be. That’s what she needed to be. Numb. Now she could do that. When she took the oxycodone and Xanax together, she felt numb. She went home to the small two-bedroom she shared with her mother. It was in a compound of mid-level brick buildings, arranged in a U shape around a sectioned parking lot. Their apartment was on the ground floor, down the hall to the right of the lobby, all the way at the end. It was warm and tight, decorated and curtained, layered with their belongings and the scents of cigarettes and air freshener. Her mother worked long hours to provide for them, leaving Tracy alone. Time enough to take her meds and hide the ones she didn’t want her mother to see.
The problem was, Tracy had been taking too much oxycodone and going to see Dr. Li too often. It didn’t matter how he wrote out the prescription; she just took two oxycodones every time she felt pain, which was several times a day. It added up to a lot—it added up to running out every three weeks, so she went back every three weeks. It was worth the extra fifty-dollar early-visit charge, coming every three weeks and getting a full month’s supply, but sometimes he asked why she was coming early. She told him what she was doing and how much she was taking. She told him that she was addicted to the oxycodone and Xanax. She talked; he wrote. Depending on how long it took him to write out two prescriptions, that’s how much time she had with him. Just enough time to write out two prescriptions. Finally, one week he had recommended another medication, Soma. “It will help you take less oxycodone,” he said.
It sure did. She didn’t have a chance to do anything else. It was the be-all and almost the end-all. She took the Soma and blacked out, and woke up only because she was being resuscitated, with her mother frantic. The EMTs all over her. The noise. The in-and-out of awake and void. The hospital, again. Tracy’s doctors told Dr. Li all about it before she had a chance to tell him herself, but of course she told him. She talked; he wrote. He had nothing to say. He had his face on him, that face he had when she talked, that made her feel like he didn’t care. But he wrote when she talked, so—
Now that she knew what the Soma could do, she wanted it again, even though her mother didn’t want her near that stuff. This was different, because she wanted to die, so she told Dr. Li to write her a script for the Soma again. She said it just like that. Did he even hear her? He had no reaction. She took the Soma, made herself a bowl of ice cream, and sat on the couch near the window, and that’s how her mother found her, with her face in the bowl of melted ice cream; it was now just another story to add to all the others. She blacked out with her face in a bowl of ice cream, but she didn’t die; in fact, she woke up and refused to go to the hospital with the EMTs, and her mother called the police to make her go to the hospital, so she went because they made her, and her mother got all upset and called Dr. Li and told him not to give her Soma anymore, and Tracy just had to keep going with everything even though it was all so much work every day just to get through.
Maybe Adderall was the answer? One of her friends had taken it, and it had given her so much energy. Maybe, she told Dr. Li during one of her next visits, maybe she should try Adderall? Dr. Li didn’t know what it was. He looked it up in a big book of medications but couldn’t find it. He didn’t know how to spell it, it turned out. He just took out the prescription pad.
“How do you spell it?” he asked.
“A-d-d-e-r-a-l-l,” said Tracy.
She talked; he wrote.
The Adderall didn’t work out, nothing ever did, really, but when something didn’t work out, they could always just go back to the basics, oxycodone and Xanax, two prescriptions for $150. She talked, he wrote, she gave him the money, and he put it right into the pocket of his white lab coat.
There are moments of blessed innocence just before you learn or see something that rocks your consciousness. Despite world news, September 11, local crimes, my job, my divorce, the overdose deaths we’d identified so far, the Tamasi letters, the Laffer murders, there were still sorrows and harms I had not been able to imagine in early 2012.
Joe, Jon, the investigators, and I continued taking shifts in their conference room, hunkering down over patient files, slowly making our way through the more than twelve hundred records as we progressively obtained permission from the Court to review all of them.
There was a time when I did not know about Tracy Howard. One minute I was unaware of her existence and the next—I was at a loss to explain her survival. There has not been a day since that I have not thought of her. Not one day.
When I close my eyes, I can see her photo again. It was clipped to the left side of the thick, worn manila folder. She had bleached-blond hair and big brown eyes. It was impossible to attribute an age to her face. She looked both defiant and in need of protection. The file contained the usual paperwork—a sparse initial evaluation form, followed by a list on plain, lined sheets with dollar amounts noted in the margins next to each visit date, and under every date a list of the prescriptions issued along with bare-bones notations.
Reading the file was like watching a looped video of a house burning down, with people screaming for help. Tracy’s mental health issues and addiction were apparent in Dr. Li’s notes, but there was no indication that he’d been alarmed or pressed into urgent action by any of it. He’d taken note of her condition with detachment, documenting without judging, except that he was supplying her with stupefying amounts of addictive substances. It was painful to read. Based on the notes, I made assumptions about her personality and her relationship with Dr. Li, imagining a willful young woman who dictated her cravings. The day I met Tracy, all my assumptions dissolved.
Joe Hall and I drove out to visit Tracy and her mother, Andrea, at home in early 2012, less than a year after Tracy’s last overdose. They welcomed us with warmth and Tracy offered to show us the lockbox where they secured her medication, to protect herself from herself. We sat in the cozy living room and I saw the couch where Tracy had passed out. Tracy and her mother were like two tigresses in captivity, the mother trying to keep her daughter alive, the daughter both grateful and trying to escape. Their love did not seem easy, but it was real. I thought about my mother and my daughter and the chain of helpfulness, helplessness, and occasional hostility that ties women together from generation to generation.
A few months later, I welcomed them both into my office. I always kept the harsh fluorescent lights off in the summer, so the big room, full of filing cabinets, was illuminated by the indirect sun. Still, it was a shabby, unfamiliar setting. In the shadows, Tracy looked like a little girl. She sat at the table, looking up at me with wide eyes, asking whether she would have to testify in front of strangers. The prospect was terrifying—but she wanted to find the strength to do it. She called me Miss Charlotte, gave sweet smiles to Joe, and delivered devastating information about herself, her father, her overdoses, in a natural and even tone, because that was just her story. She didn’t realize how much it took not to curse the world when you heard it.
I met her doctors and visited two psychiatric hospitals where she had been treated. In one of them, I wandered a long, empty hallway looking for the ladies’ room. A staff member watched me with wary eyes from a doorway. Two male patients appeared at the end of the hallway and began walking in our direction. “I’d lock that door behind you,” said the staff member, before turning to close herself in her office.
Tracy and her mother were scheduled to take the stand. Peter and I were nervous wrecks. How were they getting to court? When would they arrive? Would Tracy feel able to testify? Would we be able to get through all the questions we wanted to ask her? How would she fare under cross-examination? We had the goods ready on the evidence cart: Tracy’s file, along with every prescription Dr. Li had ever written for her and records from countless ER admissions—but would the young woman even make it into the witness seat?
“I can do this, Miss Charlotte,” Tracy assured me in the hallway outside the courtroom, before the doors opened. “I want to do this for those kids who died.”
She took the stand holding a small stuffed animal, a hand-sized fabric dog made by Victoria’s Secret with romantic messages printed on the canvas—“call me baby,” “I ♥ French kissing,” “in your dreams.” It was as childish as it was risqué. The truth, as she told it, was raw. “[M]y mommy helps me the most,” she told the jury. “I love my mom.” She spoke of her despair with simple honesty, as though every person on earth walked around hoping for the end. She told the story of her father’s suicide as though that was a definition of childhood—and for her, it was.
“Did you take the pills in excess of the level he prescribed to you?” Belair pressed on cross-examination.
Tracy answered without hesitation. “I was trying to kill myself, yes.”
Tracy admitted the lies she had told Dr. Li and defied Belair’s attempts to mischaracterize her testimony. When he tried, for instance, to confirm the fiction of Dr. Li’s family meeting with Tracy’s father and stepmother, she clutched her dog and fixed her eyes on him: “How can I have a stepmom,” she asked, “if my daddy’s dead?”
As I watched Tracy testify and squeeze her stuffed animal, I thought about the difference between our outsides and our insides. We never know what is in someone’s mind or heart. We can only judge based on the evidence we can see and hear. And it’s never enough—we can never understand everything or achieve simple, perfect human interactions. I thought about my daughter, crying in her room at night, and my inability to help her because I was clouded by tremendous love and guilt and the built-in biases of my own childhood. I knew I could do better—but how? I looked at Peter and wondered why it was so hard for us to maintain a simple, professional relationship when we both strived for good hearts and were fighting so hard on the same side. My ex-husband, he was far from perfect, but what was I missing about my own behavior? Would we ever find a way to hear each other? Was it enough to keep trying?
At the end of the day that day, I knew more about courage, thanks to Tracy. I also knew more about the ferocity of a mother whose child is threatened, thanks to Andrea Howard, who told the jury about a call she made to Dr. Li after one of Tracy’s overdoses.
Andrea lifted her chin and stared at Dr. Li. “I tell [sic] him he was a scumbag. He was a motherfucker. He was a murderer. He was a killer.”
“Thank you,” Peter responded. “What did Dr. Li say?”
“Nothing. He was very calm.”
Dr. Li was, in fact, very calm as he responded to his attorney’s questions about his “treatment” of Tracy Howard, from May 2009 until August 2011.
“Doctor,” Belair asked, “up to and including January 2, 2011, had you at all times prescribed the medications that you did for this patient in the exercise of good faith in trying to help her with her pain problems?”
Dr. Li nodded. “Yes.”
“Up until […] January 2, 2011, had the patient been compliant with your directions in this regard?”
Dr. Li’s tone was even. “The compliance, I don’t see significant she is not complying.”
He had just reviewed her chart with Belair, which documented three overdoses, including two suicide attempts, and countless early visits. In fact, according to Dr. Li’s own records, Tracy had never been compliant with his instructions. Perhaps he failed to see a “significant” lack of compliance overall because he’d managed to dismiss every single warning and incident at the time and then again on the witness stand.
His first warning about Tracy Howard had come just after her first visit in May 2009. “Call from New York Queens Hospital,” Dr. Li had noted in his chart. “The patient took too much Xanax. Needs detoxification from Benzo. Benzo means benzodiazepine. Xanax.”
When Tracy Howard returned to Dr. Li’s office ten days later, he asked her about the incident. “So I ask her […],” Dr. Li testified, “ ‘why you went to hospital’ and what was happening. And she reply to me, she went to hospital because she has upper back pain.”
Contrary to the information Dr. Li had received from a fellow physician, Tracy Howard denied that she’d taken too much Xanax. “She say she didn’t take too much,” Dr. Li explained. “She said she went to hospital because the upper back pain.”
“Did you accept what she said?” Belair asked.
“Yes.”
“How did she appear when she was in your office?”
Dr. Li spoke plainly, without concern. “She appeared mentally normal. She is not like sedating. It’s nothing special. Nothing shows she have intoxication from benzodiazepine, like sleepiness, something like sedated.”
Dr. Li didn’t stop prescribing. “I prescribe oxycodone thirty milligram times ninety pill,” he said, “take one pill TID, means three times a day. And Xanax two milligrams, sixty pill, twice a day. Now I have seen the patient twice. My impression is she need Xanax for control her anxiety or panic attack. This patient, the way she talked to me, the way she appeared to me, is the personality have high level of anxiety and easy to get panic attack. I believe she needs Xanax for control her anxiety. That’s why I continue the same dose of Xanax. Two pills a day. Two milligram, two pills a day, is not a very high dose. It’s not going to cause overdosing, this dosage.”
Even though it already had, I thought.
In addition to Xanax and oxycodone, he prescribed Adderall, telling the jury that Tracy needed it to “concentrate,” to “focus on study.” Tracy came every three weeks and received a full month’s supplies. Despite early visits, excuses, medication requests, hospital procedures, injuries, Dr. Li continued prescribing—and even though she was a Medicare beneficiary, he was making her pay cash for prescriptions. He even kept a running tally of the money she owed him in the margins of her patient chart.
“The next one,” Dr. Li said, referring to another call from another doctor, “is March 20, 2010. North Shore Hospital call. Patient to hospital. Run out meds. Means run out of medication. And also positive for heroin.”
As it turned out, Tracy Howard came to see him the same day. It had been less than three weeks since her last visit.
Dr. Li read from his notes in Tracy’s patient file. “ ‘March 20, 2010. As her word, “I try to hurt myself. My mother die. I was so depressed.” Patient was on psychiatrist floor for seven day on Seroquel fifty milligram.’ ”
Tracy’s mother, of course, was not dead—Dr. Li had just seen her in court a few weeks earlier. Belair and Dr. Li did not take the time to clarify this point of confusion. Instead, Dr. Li explained that since Tracy claimed to be feeling “better,” he prescribed again that day, and the next time, and the next for more than another year.
The next warning came on November 13, 2010. A note written in Anna Guo’s handwriting indicated that the office had received a call: the patient took Soma and had a bad reaction. As it happened, Tracy came to see Dr. Li later the same day. “Pain’s the same,” she told Dr. Li. “I’m going to Florida,” she added, so he gave her more prescriptions. No Soma that time, but within a few months he prescribed it again.
Yet another physician called Dr. Li on November 30, 2010, with a report about Tracy Howard’s condition. “ ‘The patient was in LIJH, Long Island Jewish Hospital, for overdose of opioid and Klonopin,’ ” Dr. Li read from his notes. “ ‘Decrease heart rate. She was “d/c” hospital. Now “d/c” means discharged from the hospital now. She was put on small methadone and then there’s a telephone number psychiatrist.’ ”
In fact, Tracy had attempted suicide again on November 19, 2010. Tracy told the doctors at Long Island Jewish that her life “sucks,” that she had been “depressed forever.” That’s why she had decided to kill herself with an overdose of pills, that’s what she’d told the doctors at LIJH, and that’s what Dr. Li would have learned if he had asked any questions or consulted the records. He also would have learned that, by the time Tracy reached the hospital, on November 19, in a state of overdose, she had used every Klonopin and Xanax pill he prescribed six days earlier. In fact, she had even purchased extra Xanax “on the street”—she had bought between nine and ten “sticks” daily. DAILY. She had given her boyfriend half her oxycodone pills—sixty pills—but she had used the remaining sixty pills. In six days. Because her life sucked and she wanted to die.
Dr. Li kept prescribing and the calls kept coming. The next warning came from Tracy Howard’s “stepfather” on January 29, 2011. “This is confusing to me,” Dr. Li testified, explaining why he disregarded the message. “I know the patient tell me her mother died and she have a stepmother. But she never told me her father died and she have a stepfather. So I just confused who is the guy making the phone call and I cannot confirm that.”
Of course, it wasn’t Tracy’s mother who had died but her father—he’d shot himself in front of her when she was a little girl. How could anyone forget that?
“July 2011,” Dr. Li continued, referring to his notes. “The Chinese note means receive doctor phone call from hospital, ask to talk to Dr. Li, but the patient’s condition unclear. The other side, the cell phone number, but when doctor, means Dr. Li, call back the person who picked up the phone said wrong number. So somebody tried to leave me [sic] and leave phone number, but when I call back and then the person says wrong number. So I cannot communicate with the person because the number is wrong or something wrong.”
When he saw Tracy again, she denied having been hospitalized, so he prescribed again.
Dr. Stan Li was Tracy Howard’s doctor. She became his victim and it is a miracle she survived his “treatment.” He just didn’t see it that way.
“So from December 4, 2010, […] through August 14, 2011,” Belair asked Dr. Li, covering the time period for which the grand jury had charged Dr. Li with reckless endangerment, “did you continue to treat your patient in good faith and attempt to help her with her pain and for […] that matter her reluctance to see a psychiatrist?”
“Yes,” answered Dr. Li.
“Did she suffer any injury, side effect, or harm during that period of time?”
“No.” […]
“Was she at risk of, was she at serious risk of injury or death by anything you did?”
“No.”
I stood at the lectern with my binders of Bates-numbered patient files before me, an image of the page we were discussing projected for the jury, my list of questions; Dr. Gharibo had his own copy of the same binder; at the defense table, Belair paged through yet another copy of both the binders and my questions, following along and taking notes.
Belair knew everything about our work with Dr. Gharibo, and the doctor’s background. He had known for a long time. Dr. Gharibo was our expert witness, so we had an obligation to disclose any prior statements he’d made about the case in addition to any information we’d supplied him about the case, and on which he had based his opinion. Also, Belair had a printed list of most of the questions I planned to ask Dr. Gharibo: since the direct examination necessarily would be long and detailed, as it covered all twenty patients in the indictment, I had prepared my questions ahead of time. Since questions often incorporate facts or naturally reflect prior conversations with a witness, they have to be disclosed in advance to the defense if they are written down. Once in a while, I improvised a question, but for the most part, Belair had a road map.
Belair had a corresponding obligation with any expert witness he was planning to call, but we had yet to find out whether he would call an expert witness, let alone their name.
During Dr. Gharibo’s direct examination, we dissected Howard’s patient file in chronological order, entry by entry, date by date, prescription by prescription. Dr. Gharibo expressed his expert opinion about Dr. Li’s treatment of Tracy Howard: “My opinion was that Dr. Li’s treatment was below the standards of care. It consisted of inadequate history and physical examination for the treatment duration. The extent of the treatment was not supported by the diagnosis. There was continued prescribing of controlled substances. Despite multiple controlled-substance-related hospitalizations and suicide attempts and illicit drug use and presence of absolute psychiatric contraindication, one of the highest psychiatric profiles was present in [this patient] consisting of bipolar disease, history of heroin overdose, anxiety, depression, and suicide risk, as well as cocaine use. There were control issues with respect to the patient’s taking controlled substances. The medication consumption was poorly controlled and that was made even further dangerous by disproportionate dose escalation. They were dangerous and unexplained, as prescribed by Dr. Li.”
Belair bided his time. Nineteen days later, on May 28, 2014, he was the one standing at the lectern with Dr. Gharibo in the hot seat. Belair did not have an obligation to advance in chronological fashion through the patient charts, follow my organizational structure, or cover any or all topics. His only limitation was that he couldn’t go beyond the scope of the direct examination. He controlled the narrative and kept it narrow: he poked in and out of the Howard records, asking Dr. Gharibo targeted questions to make his points, and ignored the rest. The points were clear: she obtained controlled substances from other doctors and Dr. Li sometimes decreased her doses of medication.
It was hard to sit through any of Belair’s cross-examination of Dr. Gharibo, but their exchanges about Tracy Howard gutted me. I hoped the jury had heard Dr. Gharibo. I hoped they had registered his outrage at the thought that a suicidal patient’s family should be given responsibility for her medications. “It’s completely inappropriate for a lot of reasons here,” Dr. Gharibo had insisted. “[…] One of them is that [the] patient is trying to kill herself, has ideas about killing herself, and that is also another absolute contraindication, you don’t give a suicidal patient the tools to kill themselves with, coupled with demonstration of loss of control, but it goes beyond that as well. The patient is also exhibiting access to the illegal drug market and other psychoactive medications such as cocaine and heroin, which she could also use to kill herself with. So, she is an absolute contraindication to continue prescribing […]. Anything has a high probability of hurting her at the minimum, if not killing her.”
It seemed like common sense. Like common humanity. And yet, it was in dispute.